A blog from the Center for Small Towns, a community outreach organization operated through the University of Minnesota, Morris. The Center prides itself on meeting the needs of small towns and organizations through a flexible, multi-faceted, community focused approach.

The Present and Future of Rural Childcare: Part III

As part of an ongoing series on rural child care, Rebecca Haider expanded on a previous post by looking into a number of regulations on infant care — a topic of great concern for providers and parents alike.

Like many expecting parents, I have spent a lot of time lately thinking about baby products and trying to find the safest (and most adorable) items for our kiddo to eat, bathe, play, and sleep with. My recent research into child care regulations has proven incredibly useful throughout this process, particularly when it comes to planning our child’s sleeping arrangement.

As I discussed in my last post, infant sleep rules were a topic of concern for many providers in Stevens county at the November town hall meeting and were discussed heatedly in the following weeks on social media sites, particularly regarding items in the crib (eg. blankets), carrying a sleeping infant, and sleeping position (on the stomach or back). When I looked up relevant statute (245A.1435 REDUCTION OF RISK OF SUDDEN UNEXPECTED INFANT DEATH IN LICENSED PROGRAMS, for those of you who might want to read it in its entirety), I found it fairly straightforward:

[The provider] must place the infant on the infant’s back, unless [they have] documentation from the infant’s physician directing an alternative sleeping position for the infant […] on a form approved by the commissioner [to be kept] on file at the licensed location. An infant who independently rolls onto its stomach after being placed to sleep on its back may be allowed to remain sleeping on its stomach if the infant is at least six months of age or [the provider] has a signed statement from the parent.

[The provider] must place the infant in a crib directly on a firm mattress with a fitted sheet […] that fits tightly on the mattress […] so it cannot be dislodged. [… The provider] must not place anything in the crib with the infant except for the infant’s pacifier.

If an infant falls asleep before being placed in a crib, [the provider] must move the infant to a crib as soon as practicable, and must keep the infant within sight of the license holder until [then]. When an infant falls asleep while being held, [the provider] must consider the supervision needs of other children in [their] care when determining how long to hold the infant before placing the infant in a crib to sleep.

Placing a swaddled infant down to sleep in a licensed setting is not recommended for an infant of any age, [and] prior to any use of swaddling for sleep by a provider licensed under this chapter, [the provider] must obtain informed written consent for the use of swaddling from the parent or guardian of the infant on a form provided by the commissioner, prepared in partnership with the Minnesota Sudden Infant Death Center.

I wanted to understand exactly why these rules were in place, so I explored the volumes of articles and reports written on the safest methods for laying a child down, preparing their crib, and what/what not to include in their sleeping area. My investigation lead to a timely publication on factors of sudden infant death syndrome (SIDS) nationwide from the January 2016 volume of Pediatrics, which was released early and has already been summarized by news, parenting, and health websites across the web.

“It is true without any qualification that it is safest for babies to sleep on their backs,” said the article’s lead researcher Dr. Richard Goldstein, a pediatrician at Boston Children’s Hospital/Dana-Farber Cancer Center. While the article discusses how prenatal development factors can lead to an “underlying vulnerability” particularly during a child’s first 6 months, “the sleep environment is still most important,” said Dr. Rachel Moon, who co-wrote an editorial published with the study. The infant’s sleep arrangement and position “are the factors we can most easily change.”

Much of the decrease in nationwide SIDS rates between 1983 and 2012 (the time period studied in the article) happened between 1994 and 1996, after the American Academy of Pediatrics first recommended placing babies on their backs to sleep (coined the “Back to Sleep” campaign), and when the importance of reducing suffocation hazards like soft bedding in cribs was brought to light. Goldstein agreed, saying “the ‘Back to Sleep’ campaign has been one of the most successful public health campaigns of our time.”

I also found a series of articles specific to Minnesota from 2012 and 2013, following the Dept. of Human Services’ 2012 “Review of Child Deaths in Minnesota Licensed Family Child Care Homes.” Minnesota has 91,000 children in licensed family child care compared to 60,000 in larger centers. Yet 83 of the 86 deaths between August 2002 to August 2012 occurred in family child care settings, with 75 percent of these deaths occurring in an unsafe sleep situation. “There’s almost 28 times as many deaths,” DHS Inspector General Jerry Kerber said. “There’s disproportionate representation. I think we can all agree.”

A 2014 Star Tribune article described how this slew of media coverage and a series of state reforms in 2013 coincided with drops in child care deaths throughout 2013 and 2014. While this is a great start, it’s impossible to determine what lead to that drop: the addition of more strict regulations, increased compliance of pre-existing rules, or some combination of the two. The “first thing we need to do is have providers follow the rules we already have,” MN Human Services Commissioner Lucinda Jesson said in 2012. “There are a number of situations where that’s not happening.” This sentiment is echoed by numerous providers, including one who closed her home daycare in 2012 partly due to growing frustrations with state regulations: “people rely on the fact that someone isn’t coming out every six months to check on them.”

Until 2014, Minnesota only required inspections every two years, but the federal Child Care and Development Block Grant Act of 2014 now requires annual inspections. While this seems promising in terms of improving quality, the state and county licensing staff are already balancing overwhelming caseloads, so more frequent inspections may only stretch them further. In fact, the 2013 Child Care Aware* report found that Minnesota had one state licensing worker for every 194 centers and averaged about one inspector per 150 homes. “With the important role effective monitoring plays in promoting child safety and program compliance with licensing, the number of programs that each licensing staff covers needs to be reduced, not increased.”

The implications of increased regulations and compliance frequency for rural child care providers are different from those for urban areas. With lower populations come fewer options for care, so the closing of one center or home-provider can be devastating for a higher proportion of the working parents. Additionally, there are often smaller pools of potential child care providers in rural areas, so recruiting new providers can be challenging. Morris provides a perfect example of both of these concerns, with a number of providers closing their doors and few new options opening. At the November town hall, a legislator asked why we didn’t see more new providers in Morris; the providers unanimously replied that “regulations” and “paperwork” were discouraging and daunting to potential newcomers.

A 2012 Star Tribune article summarized the challenge well: “As they work to improve safety, state regulators must strike a careful balance: how to reduce deaths and safety violations without overburdening child-care providers [and licencors], who are critical players in the state economy and essential to thousands of Minnesota families.”

4 thoughts on “The Present and Future of Rural Childcare: Part III”

Thanks for asking! The part of the statute related to swaddling reads as follows (in its entirety):
Placing a swaddled infant down to sleep in a licensed setting is not recommended for an infant of any age and is prohibited for any infant who has begun to roll over independently. However, with the written consent of a parent or guardian according to this paragraph, a license holder may place the infant who has not yet begun to roll over on its own down to sleep in a one-piece sleeper equipped with an attached system that fastens securely only across the upper torso, with no constriction of the hips or legs, to create a swaddle. Prior to any use of swaddling for sleep by a provider licensed under this chapter, the license holder must obtain informed written consent for the use of swaddling from the parent or guardian of the infant on a form provided by the commissioner and prepared in partnership with the Minnesota Sudden Infant Death Center.

This rule involves two aspects: following “best practices” according to scientific research, and respecting the parents’ wishes for their child.
1) Since there is no literature that has found a significant benefit from swaddling, the state cannot soundly encourage providers to use the practice. Additionally, the provider is only permitted to swaddle the child until they have started to roll over independently (the age at which additional fabric has been shown to be more harmful than beneficial due to inconsistent/inappropriate usage). Lastly, the rule includes restrictions on the type of swaddle since certain practices have been shown to be safer for the child, such as the “one-piece sleeper […] that fastens securely.”
2) Some providers had utilized swaddling without consent from or awareness of the parents (largely to make the infants easier to manage). This led to the inclusion of “obtaining informed written consent” from the parents.

All in all, the statute as a whole is written to minimize potential risk factors for SIDS or sleep-related deaths. It is important to note that since these rules went into place, the number of infant deaths has drastically decreased, so something is working!

So thankful for your article Becca! It is important to share this valuable information. It is unfortunate that rules need to be applied to keep our children safe, but it does make a huge difference! According to the most recent report on infant mortality dated October 2015, West Central Minnesota (us) holds the 2nd highest rate of infant mortality in the state. We have to share information in order to change this, even if it goes against the most common practices. It breaks my heart to see items being used by families simply because they have not been informed. Our goal is to change this. Information and Education can go a long way in not only keeping the child safe, but protecting care givers as well.

Thanks Theresa!
I completely agree that sharing this kind of information is the best way to initiate changes that will benefit parents, their children, and providers alike.
I haven’t seen the most recent report and couldn’t find it online, so I would love if you could send it my way.
Thanks again!